A comparison of the demographics, injury patterns and outcome data for patients injured in motor vehicle collisions who are trapped compared to those patients who are not trapped

A data-driven algorithm to support the clinical decision-making of patient extrication following a road traffic collision

BACKGROUND

Some patients involved in a road traffic collision (RTC) are physically entrapped and extrication is required to provide critical interventions. This can be performed either in an expedited way, or in a more controlled manner. In this study we aimed to derive a data-driven extrication algorithm intended to be used as a decision-support tool by on scene emergency service providers to decide on the optimal method of patient extrication from the vehicle.

METHODS

A retrospective observational study was performed of all trauma patients trapped after an RTC who were attended by a Helicopter Emergency Medical Service (HEMS) in the United Kingdom between March 2013 and December 2021. Variables were identified that were associated with the need for HEMS interventions (as a surrogate for the need for expedited extrication), based on which a practical extrication algorithm was devised.

RESULTS

During the study period 12,931 patients were attended, of which 920 were physically trapped. Patients who scored an "A" on the AVPU score (n = 531) rarely required HEMS interventions (3%). Those who did were characterised by a shorter than average (29 vs. 37 min) 999/112 emergency call to HEMS on-scene arrival interval. A third of all patients responding to voice required HEMS interventions. Absence of a patent airway (OR 6.98 [1.74-28.03] p < .001) and the absence of palpable radial pulses (OR 9.99 [2.48-40.18] p < .001) were independently associated with the need for (one or more) HEMS interventions in this group. Patients only responding to pain and unresponsive patients almost invariably needed HEMS interventions post extrication (90% and 86% respectively). Based on these findings, a practical and easy to remember algorithm "APEX" was derived.

CONCLUSION

A simple, data-driven algorithm, remembered by the acronym "APEX", may help emergency service providers on scene to determine the preferred method of extrication for patients who are trapped after a road traffic collision. This has the potential to facilitate earlier recognition of a 'sick' critical patient trapped in an RTC, decrease entrapment and extrication time, and may contribute to an improved outcome for these patients.

The variables predictive of ambulance non-conveyance of patients in the Western Cape, South Africa

Introduction

Emergency medical service (EMS) resources are limited and should be reserved for incidents of appropriate acuity. Over-triage in dispatching of EMS resources is a global problem. Analysing patients that are not transported to hospital is valuable in contributing to decision-making models/algorithms to better inform dispatching of resources. The aim is to determine variables associated with patients receiving an emergency response but result in non-conveyance to hospital.

Methods

A retrospective cross-sectional study was performed on data for the period October 2018 to September 2019. EMS records were reviewed for instances where a patient received an emergency response but the patient was not transported to hospital. Data were subjected to univariate and multivariate regression analysis to determine variables predictive of non-transport to hospital.

Results

A total of 245 954 responses were analysed, 240 730 (97.88 %) were patients that were transported to hospital and 5 224 (2.12 %) were not transported. Of all patients that received an emergency response, 203 450 (82.72 %) patients did not receive any medical interventions. Notable variables predictive of non-transport were green (OR 4.33 (95 % CI: 3.55-5.28; p<0.01)) and yellow on-scene (OR 1.95 (95 % CI: 1.60-2.37; p<0.01).Incident types most predictive of non-transport were electrocutions (OR 4.55 (95 % CI: 1.36-15.23; p=0.014)), diabetes (OR 2.978 (95 % CI: 2.10-3.68; p<0.01)), motor vehicle accidents (OR 1.92 (95 % CI: 1.51-2.43; p<0.01)), and unresponsive patients (OR 1.98 (95 % CI: 1.54-2.55; p<0.01)). The highest treatment predictors for non-transport of patients were nebulisation (OR 1.45 (95 % CI: 1.21-1.74; p<0.01)) and the administration of glucose (OR 4.47 (95 % CI: 3.11-6.41; p<0.01)).

Conclusion

This study provided factors that predict ambulance non-conveyance to hospital. The prediction of patients not transported to hospital may aid in the development of dispatch algorithms that reduce over-triage of patients, on-scene discharge protocols, and treat and refer guidelines in EMS.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

BACKGROUND

Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

RESULTS

This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

CONCLUSION

A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

A biomechanical study to compare spinal movement in a healthy volunteer during extrication between 'chain cabling' and 'roof off' methods of extrication

INTRODUCTION

Following a motor vehicle collision some patients will remain trapped. Traditional extrication methods are time consuming and focus on movement minimisation and mitigation. 'Chain cabling' is an alternative method of extrication used in some countries. The optimal extrication strategy and the effect of extrication methods on spinal movement is unknown. This study compares 'chain cabling' to the established roof removal method of extrication on spinal movement.

METHODS

Biomechanical data were collected using Inertial Measurement Units on a single healthy volunteer during multiple experiments. The extrication types examined were chain cabling and roof removal. Measurements were recorded at the cervical and lumbar spine, and in the anteroposterior (AP) and lateral (LR) planes. Total movement (travel), maximal movement, mean, standard deviation and confidence intervals are reported.

RESULTS

Eight experiments were performed using each technique. The smallest mean overall movements were recorded during roof-off extrication (cervical spine 0.6 mm for AP and LR, lumbar spine 3.9 mm AP and 0.3 mm LR). The largest overall mean movements were seen with chain cabling extrication (cervical spine AP 5.3 mm. LR 6.1 mm and lumbar spine 6.8 mm AP and 6.3 mm LR).

CONCLUSION

In this study of a healthy volunteer, roof-off extrication was associated with less movement than chain cabling. The movement associated with chain cabling extrication was similar to that previously collected for other extrication types.

Understanding people's experiences of extrication while being trapped in motor vehicles: a qualitative interview study

OBJECTIVE

To explore patient's experience of entrapment and subsequent extrication following a motor vehicle collision and identify their priorities in optimising this experience.

DESIGN

Semistructured interviews exploring the experience of entrapment and extrication conducted at least 6 weeks following the event. Thematic analysis of interviews.

SETTING

Single air ambulance and spinal cord injury charity in the UK.

PARTICIPANTS

10 patients were recruited and consented; six air ambulance patients and two spinal cord injury charity patients attended the interview. 2 air ambulance patients declined to participate following consent due to the perceived potential for psychological sequelae.

RESULTS

The main theme across all participants was that of the importance of communication; successful communication to the trapped patient resulted in a sense of well-being and where communication failures occurred this led to distress. The data generated three key subthemes: 'on-scene communication', 'physical needs' and 'emotional needs'. Specific practices were identified that were of use to patients during entrapment and extrication.

CONCLUSIONS

Extrication experience was improved by positive communication, companionship, explanations and planned postincident follow-up. Extrication experience was negatively affected by failures in communication, loss of autonomy, unmanaged pain, delayed communication with remote family and onlooker use of social media. Recommendations which will support a positive patient-centred extrication experience are the presence of an 'extrication buddy', the use of clear and accessible language, appropriate reassurance in relation to co-occupants, a supportive approach to communication with family and friends, the minimisation of onlooker photo/videography and the provision of planned (non-clinical) follow-up.

A Delphi study of rescue and clinical subject matter experts on the extrication of patients following a motor vehicle collision

BACKGROUND

Approximately 1.3 million people die each year globally as a direct result of motor vehicle collisions (MVCs). Following an MVC some patients will remain trapped in their vehicle; these patients have worse outcomes and may require extrication. Following new evidence, updated multidisciplinary guidance for extrication is needed.

METHODS

This Delphi study has been developed, conducted and reported to CREDES standards. A literature review identified areas of expertise and appropriate individuals were recruited to a Steering Group. The Steering Group formulated initial statements for consideration. Stakeholder organisations were invited to identify subject matter experts (SMEs) from a rescue and clinical background (total 60). SMEs participated over three rounds via an online platform. Consensus for agreement / disagreement was set at 70%. At each stage SMEs could offer feedback on, or modification to the statements considered which was reviewed and incorporated into new statements or new supporting information for the following rounds. Stakeholders agreed a set of principles based on the consensus statements on which future guidance should be based.

RESULTS

Sixty SMEs completed Round 1, 53 Round 2 (88%) and 49 Round 3 (82%). Consensus was reached on 91 statements (89 agree, 2 disagree) covering a broad range of domains related to: extrication terminology, extrication goals and approach, self-extrication, disentanglement, clinical care, immobilisation, patient-focused extrication, emergency services call and triage, and audit and research standards. Thirty-three statements did not reach consensus.

CONCLUSION

This study has demonstrated consensus across a large panel of multidisciplinary SMEs on many key areas of extrication and related practice that will provide a key foundation in the development of evidence-based guidance for this subject area.

Traumatisme et température

Le patient traumatisé est exposé à l’hypothermie. La mortalité des traumatisés hypothermes est multipliée par quatre ou cinq. Les interactions de l’hypothermie avec l’hémostase et le système cardiovasculaire sont délétères. Les effets sur la coagulation sont multiples et concourent directement à la surmortalité faisant de l’hypothermie une composante majeure de la « triade létale ». Les causes d’hypothermie chez le patient traumatisé sont multiples : 1) environnementales, le risque augmente quand la température ambiante diminue ; 2) cliniques, le risque augmente avec la gravité ; et aussi 3) thérapeutiques, par exemple par la perfusion de solutés à température ambiante. Une prise en charge optimale repose sur une mesure précoce et un monitorage continu de la température corporelle. L’objectif thérapeutique est de maintenir une température corporelle au moins égale à 36 °C. Limiter le déshabillage du patient, le protéger du froid avec une couverture de survie, l’installer rapidement dans une ambulance chauffée, recourir à des dispositifs de réchauffement actifs, perfuser des solutés réchauffés sont les éléments fondamentaux de la prise en charge d’un patient traumatisé, potentiellement hypotherme.

Sex-disaggregated analysis of the injury patterns, outcome data and trapped status of major trauma patients injured in motor vehicle collisions: a prespecified analysis of the UK trauma registry (TARN)

OBJECTIVES

To identify the differences between women and men in the probability of entrapment, frequency of injury and outcomes following a motor vehicle collision. Publishing sex-disaggregated data, understanding differential patterns and exploring the reasons for these will assist with ensuring equity of outcomes especially in respect to triage, rescue and treatment of all patients.

DESIGN

We examined data from the Trauma Audit and Research Network (TARN) registry to explore sex differences in entrapment, injuries and outcomes. We explored the relationship between age, sex and trapped status using multivariate logistical regression.

SETTING

TARN is a UK-based trauma registry covering England and Wales.

PARTICIPANTS

We examined data for 450 357 patients submitted to TARN during the study period (2012-2019), of which 70 027 met the inclusion criteria. There were 18 175 (26%) female and 51 852 (74%) male patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

We report difference in entrapment status, injury and outcome between female and male patients. For trapped patients, we examined the effect of sex and age on death from any cause.

RESULTS

Female patients were more frequently trapped than male patients (female patients (F) 15.8%, male patients (M) 9.4%; p<0.0001). Trapped male patients more frequently suffered head (M 1318 (27.0%), F 578 (20.1%)), face, (M 46 (0.9%), F 6 (0.2%)), thoracic (M 2721 (55.8%), F 1438 (49.9%)) and limb injuries (M 1744 (35.8%), F 778 (27.0%); all p<0.0001). Female patients had more injuries to the pelvis (F 420 (14.6%), M 475 (9.7%); p<0.0001) and spine (F 359 (12.5%), M 485 (9.9%); p=0.001). Following adjustment for the interaction between age and sex, injury severity score, Glasgow Coma Scale and the Charlson Comorbidity Index, no difference in mortality was found between female and male patients.

CONCLUSIONS

There are significant differences between female and male patients in the frequency at which patients are trapped and the injuries these patients sustain. This sex-disaggregated data may help vehicle manufacturers, road safety organisations and emergency services to tailor responses with the aim of equitable outcomes by targeting equal performance of safety measures and reducing excessive risk to one sex or gender.

Do entrapment, injuries, outcomes and potential for self-extrication vary with age? A pre-specified analysis of the UK trauma registry (TARN)

Background

Motor vehicle collisions (MVCs), particularly those associated with entrapment, are a common cause of major trauma. Current extrication methods are focused on spinal movement minimisation and mitigation, but for many patients self-extrication may be an appropriate alternative. Older drivers and passengers are increasingly injured in MVCs and may be at an increased risk of entrapment and its deleterious effects. The aim of this study is to describe the injuries, trapped status, outcomes, and potential for self-extrication for patients following an MVC across a range of age groups.

Methods

This is a retrospective study using the Trauma Audit and Research Network (TARN) database. Patients were included if they were admitted to an English hospital following an MVC from 2012 to 2019. Patients were excluded when their outcomes were not known or if they were secondary transfers. Simple descriptive analysis was used across the age groups: 16–59, 60–69, 70–79 and 80+  years. Logistic regression was performed to develop a model with known confounders, considering the odds of death by age group, and examining any interaction between age and trapped status with mortality.

Results

70,027 patients met the inclusion criteria. Older patients were more likely to be trapped and to die following an MVC (p < 0.0001). Head, abdominal and limb injuries were more common in the young with thoracic and spinal injuries being more common in older patients (all p < 0.0001). No statistical difference was found between the age groups in relation to ability to self-extricate. After adjustment for confounders, the 80 + age group were more likely to die if they were trapped; adjusted OR trapped 30.2 (19.8–46), not trapped 24.2 (20.1–29.2).

Conclusions

Patients over the age of 80 are more likely to die when trapped following an MVC. Self-extrication should be considered the primary route of egress for patients of all ages unless it is clearly impracticable or unachievable. For those patients who cannot self-extricate, a minimally invasive extrication approach should be employed to minimise entrapment time.

Assessing spinal movement during four extrication methods: a biomechanical study using healthy volunteers

Background

Motor vehicle collisions are a common cause of death and serious injury. Many casualties will remain in their vehicle following a collision. Trapped patients have more injuries and are more likely to die than their untrapped counterparts. Current extrication methods are time consuming and have a focus on movement minimisation and mitigation. The optimal extrication strategy and the effect this extrication method has on spinal movement is unknown. The aim of this study was to evaluate the movement at the cervical and lumbar spine for four commonly utilised extrication techniques.

Methods

Biomechanical data was collected using inertial Measurement Units on 6 healthy volunteers. The extrication types examined were: roof removal, b-post rip, rapid removal and self-extrication. Measurements were recorded at the cervical and lumbar spine, and in the anteroposterior (AP) and lateral (LAT) planes. Total movement (travel), maximal movement, mean, standard deviation and confidence intervals are reported for each extrication type.

Results

Data from a total of 230 extrications were collected for analysis. The smallest maximal and total movement (travel) were seen when the volunteer self-extricated (AP max = 2.6 mm, travel 4.9 mm). The largest maximal movement and travel were seen in rapid extrication extricated (AP max = 6.21 mm, travel 20.51 mm).

The differences between self-extrication and all other methods were significant (p < 0.001), small non-significant differences existed between roof removal, b-post rip and rapid removal.

Self-extrication was significantly quicker than the other extrication methods (mean 6.4 s).

Conclusions

In healthy volunteers, self-extrication is associated with the smallest spinal movement and the fastest time to complete extrication. Rapid, B-post rip and roof off extrication types are all associated with similar movements and time to extrication in prepared vehicles.

The role of cervical collars and verbal instructions in minimising spinal movement during self-extrication following a motor vehicle collision - a biomechanical study using healthy volunteers

Background

Motor vehicle collisions account for 1.3 million deaths and 50 million serious injuries worldwide each year. However, the majority of people involved in such incidents are uninjured or have injuries which do not prevent them exiting the vehicle. Self-extrication is the process by which a casualty is instructed to leave their vehicle and completes this with minimal or no assistance. Self-extrication may offer a number of patient and system-wide benefits. The efficacy of routine cervical collar application for this group is unclear and previous studies have demonstrated inconsistent results. It is unknown whether scripted instructions given to casualties on how to exit the vehicle would offer any additional utility.

The aim of this study was to evaluate the effect of cervical collars and instructions on spinal movements during self-extrication from a vehicle, using novel motion tracking technology.

Methods

Biomechanical data on extrications were collected using Inertial Measurement Units on 10 healthy volunteers. The different extrication types examined were: i) No instructions and no cervical collar, ii) No instructions, with cervical collar, iii) With instructions and no collar, and iv) With instructions and with collar. Measurements were recorded at the cervical and lumbar spine, and in the anteroposterior (AP) and lateral (LAT) planes. Total movement, mean, standard deviation and confidence intervals are reported for each extrication type.

Results

Data were recorded for 392 extrications. The smallest cervical spine movements were recorded when a collar was applied and no instructions were given: mean 6.9 mm AP and 4.4 mm LAT. This also produced the smallest movements at the lumbar spine with a mean of 122 mm AP and 72.5 mm LAT.

The largest overall movements were seen in the cervical spine AP when no instructions and no collar were used (28.3 mm). For cervical spine lateral movements, no collar but with instructions produced the greatest movement (18.5 mm). For the lumbar spine, the greatest movement was recorded when instructions were given and no collar was used (153.5 mm AP, 101.1 mm LAT).

Conclusions

Across all participants, the most frequently occurring extrication method associated with the least movement was no instructions, with a cervical collar in situ.